We report a case involving the incidental finding of enterolithis in Meckel’s diverticulum. Only a small number of Meckel’s diverticulum lithiasis cases have been described in literature. Meckel’s diverticulum can be responsible of bleeding, perforation, obstruction and, rarely, to enteroliths formation. We argue that in patients with calcifications on plain abdominal film of no obvious etiology, Meckel’s diverticulum lithiasis should be included in differential diagnosis.

Key words: Meckel’s diverticulum, enteroliths

Introduction

Meckel’s diverticulum is the most common congenital diverticulum of the small bowel, occurring in about 2% of the general population [1]. In 4.2% it becomes symptomatic during lifetime, due to its complications: acute gastrointestinal bleeding, intussusception, inflammation or perforation. Enterolith formation is a rare complication of Meckel’s diverticulum, only 50 cases have been reported so far [2].

Case report

The patient is a 6-year-old girl who was complaining of right hip pain. The patient was otherwise healthy and did not accuse any abdominal symptoms. There was no history of prior abdominal surgery. An antero-posterior and profile radiographs of the hips showed, as an incidental finding, multiple stones in the right lower abdomen (Fig.1).

Figure 1. Hips radiograph demonstrates multiple stones (arrow) in the right lower quadrant with peripheral calcification and a radiolucent center.

The stones had peripheral calcifications and a radiolucent center. Ultrasound examination of the upper abdomen revealed normal biliary tree. On the CT scan of the abdomen could be seen multiple structures with either complete or only peripheral calcifications in right iliac fossa. Connection with a small bowel loop was noted (Fig.2). On celiotomy a large Meckel’s diverticulum was found at about 40 cm proximal to the ileocecal valve (Fig.3). Palpation revealed the presence of multiple enteroliths inside Meckel’s diverticulum. The stomach, the duodenum, the colon and the rest of the small bowel were normal. Diverticulectomy and segmental ileal resection were performed. Histopathologic examination of the Meckel’s diverticulum showed inflammatory small bowel modification without ectopic gastric tissue (Fig.4). Biochemical examination showed pits with dark crust (Fig.5). The postoperative course was uneventful and the patient was discharged on the 10th postoperative day.

Figure 2. CT scan of the lower abdomen

Figure 3. Intraoperative image of a 4.0 x 2.5-cm Meckel’s diverticulum located on the antimesenteric side of the ileum.

The differential diagnosis of the calcifications on plain abdominal radiography includes biliary and urinary calculi, calcified lymph nodes, teratoma of the mesentery, enteroliths. In this case, the differential diagnosis can be shortened to enterolithiasis of the small bowel because the appearance of the calcifications suggests stone formation in an area of stasis and CT demonstrates that the calcifications are within a stucture connected to small bowel. In the small bowel a Meckel’s diverticulum is the most common site of stone formation, which is a rare complication. Calcified structures can sometimes be misinterpreted as teeth-like calcifications suggestive of teratoma. In this case a teratoma was ruled out because the mass surrounding the calcifications is connected to small bowel and the shape of calcifications is not typical of dental growth. Meckel’s diverticulum is the most common congenital diverticulum of the small intestine occurring in abous diverticulum showed inflammatory small bowel modification without ectopic gastric tissue (Fig.4). Biochemical examination showed pits with dark crust (Fig.5). The postoperative course was uneventful and the patient was discharged on the 10th postoperativt 0,3 - 3% of the population at autopsy, typically 60 cm from the ileocecal valve[3]. Enterolith formation is a rare complication of Meckel’s diverticulum. Although the alkalinity of the distal small bowel favors precipitation of mineral salts, the wide nelum enteroliths reported were most often multiple (75%) and occurred more preferentially in diverticuli that do not contain ectopic gastric mucosa [6].

The presence of stones in Meckel’s diverticulum predisposes to small bowel obstruction by promoting local inflammation and intussusception or by impaction of the enterolith following its extrusion from the diverticulum. In a study from Mayo Clinic concerning1476 patients, the morbidity (20%) and mortality (3%) in the asymptomatic group was higher than the morbidity (13%) and mortality (0%) in the symptomatic group[7]. The operative management includes enterolith removal and resection of Meckel’s diverticulum to prevent recurrent stone formation and further complications.